Early Intervention Orthodontics: A Case Study

In my clinical opinion, the value of early intervention in cases of orthodontic crowding cannot be overstated. By taking advantage of a child’s natural oral growth and development between the ages of 7 and 12, functional appliances can course-correct, as it were, what would otherwise become a complicated case of crowded secondary dentition, improper bite development, and airway constriction.

Waiting for obviously crowded secondary dentition to fully erupt creates a common misconception that the child’s teeth are too big for the mouth, often leading to unnecessary extractions and distalizations in order to align whatever teeth that will fit. Crowding is never that simple, however. In most cases, it isn’t that the teeth are too big or that the mouth is too small; it’s that the natural growth and development of the arches is inhibited in some way. Childhood allergies and other airway constraints that trigger mouth-breathing habits are often the primary cause of improper arch development. Early intervention with functional appliances can not only restore the proper arch development, but also improve airway constrictions by making more room for the tongue.

Let’s take a look at a classic case of a successful first phase of early intervention orthodontics.

Initial Presentation

Before Sequence
In this case, our patient is a 8 year-old boy who presents with very crowded primary dentition with little room for proper secondary eruption.

  • Both arches are small and narrow, and the palate is vaulted.
  • His occlusion is Class II on both sides, with the mandible resting in a very distalized position.
  • Airway issues are already a problem for our young patient and he is understandably already extremely anxious about impressions and bite registrations for appliances.
  • The impression appointment is challenging, with the patient spitting out the materials before they are completely set. However, with the support of his mother in making another attempt, we are able to help him through the discomfort and capture a usable set of impressions.

A treatment plan of functional appliances to move the teeth, expand the arches, bring his mandible forward, and create more room for guided secondary eruption is commenced.

Case Progress After Phase One Treatment

After Sequence
After 18 months of active treatment, our patient now has enough room for the incoming secondary dentition.

  • He is now in a holding pattern while the second molars erupt and lock cusps.
  • The arches are now properly shaped and wide enough to receive all the teeth.
  • The palate is no longer vaulted and allows adequate space for the tongue.
  • The mandible is in a class I position.
  • His mother reports that he is sleeping better and the night snoring had stopped.
  • Braces will only be necessary if final eruption of the secondary teeth reveals rotational issues that need to be addressed.
  • Treatment in braces would likely be for less than a year, if at all.

Without early orthodontic intervention, this patient most certainly would have required many more months in braces to correct the crowding and rotational issues that would have developed if the secondary dentition had been allowed to erupt on their own. Headgear and/or extractions may even have been prescribed. Without palatal expansion, oral breathing habits would likely have worsened and the arches may have narrowed even further, causing even more airway constriction. By intervening early in what was obviously improper development of the oral cavity, we were able to help this child avoid much longer and more complicated treatment later on.

My hope is that someday all children will have access to this kind of orthodontic correction and that unnecessary extractions and distalization procedures will become a thing of the past. If you are interested in learning more about early intervention orthodontics and how you might be able to integrate some of these treatments into your own practice, I hope that you will join me for my upcoming course Early Orthodontic Intervention with Functional Appliances offered in partnership with the OAGD.

OAGD Study Club Announced for 2014

OAGD Study Club Page PhotoI’m thrilled to announce a new study club that I will be offering in partnership with the Oregon Academy of General Dentistry beginning in October 2014. Early Orthodontic Intervention with Functional Appliances will offer hands-on instruction in the use of functional appliances for guided eruption of the secondary dentition. Orthopedic health, airway and tongue issues, and early growth problems can all be supported and improved with the proper use of functional appliances during this critical phase of secondary eruption.

This four-session course will teach you how to examine, assess, prepare, and finish cases in a small group setting. Hands-on sections of the course will focus on taking proper records, impressions and bite registrations for optimal appliance construction, adjustment, delivery, and repair. Support and supervision of actual case work within your practice is also available and encouraged during this study club.

So many of the functional disorders of the jaw that adults experience can be prevented in childhood through the use of functional appliances to support natural growth and development. Airway development is also extremely important at this age, and research is demonstrating more and more that interceptive orthodontic treatment may actually help reduce the development of oral sleep apnea in adulthood. I hope that you will join me for this unique opportunity to learn how to help your youngest patients avoid or reduce the development of joint disorders, permanent tooth extraction, and other extensive orthodontic treatments as teenagers or adults.

For more information and to register for the course, please visit the Early Orthodontic Intervention with Functional Appliances page. Course space is limited to 10 dentists and their staff, so please register early.

The Preventive Nature of Interceptive Orthodontics

When I started taking courses to learn about TMD treatment almost 30 years ago, I also began my studies in early childhood growth and development. This is when I first became exposed to the multiple factors that can influence and retard the normal growth patterns in occlusal development and overall TMJ function. When these compromising factors are present, the permanent teeth are often never able to reach their full eruption potential. A deep bite, a reverse curve of spee, and/or a class II position for the mandible in addition to crowding are generally the result.

These developmental pathologies most commonly trace back to long-standing childhood breathing issues. For multiple reasons both anatomical and environmental, many children are unable to breathe through their noses regularly and easily. These children become chronic mouth-breathers – habitually breathing through the mouth to get the oxygen the body needs to survive, but also subjecting these same children to a host of developmental anomalies that accompany a mouth-breathing habit.

If this habit is not identified and addressed by parents and pediatricians, children may not learn to swallow correctly. They may develop narrow arches with crowded teeth and a high palatal vault. And frequently, they do not sleep well. All of these conditions can perpetuate and exacerbate the original breathing issue.

Certainly as orthodontic providers, we can help these children even as teenagers and into adulthood by moving the teeth, straightening the incisors, and giving them a beautiful smile. But if the original factors that caused the problem are not addressed, like mouth-breathing related to allergies or nasal blockages, orthodontic relapse (sometimes severe) is an all too common result.

In the 30 years since I began my exploration of the relationships between TMJ disorders and early childhood occlusal development, I have become more and more convinced that most people can be saved from years of pain and dysfunction with the appropriate multi-faceted approach to early bite development. Early growth analysis combined with guided eruption through interceptive orthodontic appliances when necessary is a great start for many children. But adjunctive treatment for airway issues may also be required to help that child maintain the corrective gains achieved through orthodontic treatment.

This November, I presented a lecture to the Columbia Orthodontic-Orthopedic Research Society on Interceptive Orthodontic Treatment and the preventive effects a successful multi-faceted approach to early occlusal development can have on the potential development of TMJ disorders and airway issues. This lecture was presented as an introduction to the seminar I will be teaching in 2014 on Interceptive Orthodontic Treatment and Functional Appliance Therapy. If you are interested in bringing this lecture to your local study club, and/or if you would like to be notified when my 2014 Interceptive Orthodontic Seminar is available for pre-registration, please contact me through the contact page on this site

Seeing Your Patients With New Eyes

Traditional dental diagnosis focuses on individual teeth, periodontal health, and how the teeth and arches relate to each other when a patient fits their teeth together. But there is more to oral health and functional occlusion than bacterial counts and simple interdigitation. The teeth function within a three-dimensional system along with the tempormandibular joints and masticatory muscles. Neuromuscular dentistry asks us to take all three of these components into account whenever we consider even the most minor changes to the teeth or bite.

Through the years I have seen many patients with technically beautiful Class I occlusions who suffer from a great deal of pain and masticatory dysfunction. I make a point of asking every patient – no matter how perfect his or her occlusion may seem – if their “bite” feels comfortable to them, and the answers I get can be amazing. Many people will say yes, they are comfortable – sometimes even when the occlusion is technically compromised. But a surprising number of people with seemingly perfect occlusion tell me no. These are some of the comments I hear:

“Which bite are you talking about? I bite differently on the right and left side.”

“I have to pull my jaw backward to get my back teeth together.”

“My bite doesn’t feel solid.”

Some of these occlusion problems are developmental, and many are related to mouth breathing and/or a compromised airway in childhood. But far too many of these cases are iatrogenic – we dentists help to cause them by doing “individual tooth” dentistry without first analyzing basic jaw function. Or we cause it by moving the teeth orthodontically to a beautiful, but ultimately dysfunctional, position.

Neuromuscular dentistry requires us to look at our patients with different eyes – to begin our diagnosis by assessing the larger picture of three dimensional jaw function first. This can be as simple as asking the patient to do some gentle stretching and then asking them to tell you which teeth touch first when they close the FIRST time. Or paying attention to the wear facets on the teeth, particularly on the anterior teeth. Or making sure the muscles of mastication are working together. Only then can we begin looking at the individual teeth and the periodontium with a more informed understanding of the dysfunctional conditions that may also be contributing to other forms of pathology in the mouth.